Basic Information
| Provider Information | |||||||||
| NPI: | 1699813584 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREENE | ||||||||
| FirstName: | ERIC | ||||||||
| MiddleName: | TODD | ||||||||
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| Credential: | LPC CSAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1167 SPRATLIN PARK DRIVE | ||||||||
| Address2: | |||||||||
| City: | GRAY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376156205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234673600 | ||||||||
| FaxNumber: | 4234673644 | ||||||||
| Practice Location | |||||||||
| Address1: | 43 CHAMPIONS AVENUE | ||||||||
| Address2: | |||||||||
| City: | BIG STONE GAP | ||||||||
| State: | VA | ||||||||
| PostalCode: | 24219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2765238300 | ||||||||
| FaxNumber: | 4234673644 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2007 | ||||||||
| LastUpdateDate: | 10/14/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 0710101620 CSAC | VA | N | Behavioral Health & Social Service Providers | Counselor | 101Y00000X | 0701003240 LPC | VA | N | Behavioral Health & Social Service Providers | Counselor | 101YP2500X | 0701003240 | VA | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 010149614 | 05 | VA | MEDICAID |